Skip to content
Safe Transitions from
Hospital to Home
HPG ensures a safe recovery after hospitalization: provider visits within 1-14 days of discharge, medication review, and ongoing support designed to keep you out of the hospital.
Your Transition, Step by Step
From discharge to stable recovery, our transitional care team walks with you every step of the way.
Discharge Coordination
Our case management team coordinates with the hospital to receive your discharge summary, medications list, and follow-up instructions. We schedule your first home or clinic visit before you leave.
Provider Visit
You will be seen in our office or via telehealth video visit within 1 to 14 days of discharge. We review your medical history, discharge instructions, and current medications, perform a physical exam, and address any new symptoms.
Medication Reconciliation
We review every medication prescribed during your hospitalization, clarify instructions, identify duplicates or dangerous interactions, and ensure you're taking the right medications at the right doses.
Vitals and Symptom Monitoring
We monitor vital signs, wound healing, fluid status, and any post-discharge symptoms. For eligible patients, our Remote Patient Monitoring program provides continuous at-home vital sign tracking.
Transition to Ongoing Primary Care
If you are happy with our services once the transition period is complete, you can become established as an HPG primary care patient.
What We Do at Every Transition Visit
Comprehensive clinical attention, not just a check-in.
Medical History Review
Complete review of discharge instructions, hospital records, and prior medical history.
Medication Reconciliation
Verify, clarify, and educate on all medications: including new prescriptions from the hospital.
Physical Examination
Vital signs, focused exam, and assessment of any new or worsening symptoms.
Wound Care
Surgical site and wound assessment, dressing changes, and coordination with wound care specialists.
Telehealth Options
Video visits available for patients who cannot receive in-person visits during the transition period.
In-Home Labs and Imaging
Order and coordinate at-home lab draws, x-rays, and other diagnostics as clinically indicated.
Home Health Coordination
Coordinate needs such as home physical therapy, occupational therapy, speech therapy, personal care assistants, and skilled nursing visits.
Why Transitional Care Matters
Up to 1 in 5 Medicare patients is readmitted within 30 days of discharge. HPG's transitional care program specifically targets the critical post-discharge window, when patients are most vulnerable to complications, medication errors, and preventable readmissions.
Early clinical intervention, consistent medication review, and ongoing monitoring are the three pillars that prevent that next hospitalization.
Who Is Transitional Care For?
HPG's transitional care program serves patients who have been discharged from a hospital or skilled nursing facility and need close clinical follow-up during the recovery period.
Medicare and most major insurance plans cover transitional care management services. Call us or ask your discharge coordinator about eligibility.
- Recent hospital discharge (any diagnosis)
- Skilled nursing facility discharge
- Post-surgical recovery at home
- Patients with complex or multiple chronic conditions
- Patients at high risk for readmission
- Patients who need medication management support
Your First Post-Discharge Visit
- Full medication review and reconciliation
- Review of hospital discharge instructions
- Physical exam and vital signs
- Wound or surgical site assessment
- Lab orders if clinically indicated
- Care plan update for ongoing management
- Follow-up visit scheduling
Transitional Care Forms
Complete your transitional care enrollment forms online: available in English and Spanish.
Frequently Asked Questions
Transitional care is structured medical follow-up in the days and weeks after a hospital or skilled nursing facility discharge. It includes a provider visit within 1 to 14 days, medication reconciliation, symptom monitoring, and care coordination to reduce the risk of complications or readmission.
Yes. Medicare Part B covers Transitional Care Management (TCM) services, which include the post-discharge physician visit and associated care coordination. Most Medicare Advantage plans also cover TCM. Call 321-235-0692 to confirm coverage for your specific plan.
Our team contacts you or your family within two business days of receiving a discharge notification to schedule the post-discharge visit. Depending on medical complexity, that visit occurs within 7 or 14 days of discharge: as clinically indicated.
Most transitional care visits take place at our office or via telehealth video visit. In select cases where a patient is unable to travel, a home visit may be arranged based on clinical need and provider availability.
If you are happy with our services once the transition period is complete, you can become established as an HPG primary care patient.
Coming Home from the Hospital?
Don't navigate recovery alone. HPG's transitional care team is ready to support you. Call today to get started.